How To Address Vascular Complications With Lower Extremity Wounds
Our contemporary knowledge and critical limb ischemia (CLI) tools have allowed us to dispel many myths regarding the endovascular treatments of lower extremity disease and CLI. These tools are not perfect but they have greatly improved over the last decade and certainly over the last two to three years. One of the biggest complaints I hear from podiatrists is “the surgeons and interventionalists in my area do not believe these things work.” Accordingly, let us take a closer look at some of these myths and the corresponding realities.
Myth: Most CLI patients get an appropriate vascular assessment. In 2008, one would hope that most, if not all, CLI patients would have at least an objective non-invasive vascular evaluation before primary amputation occurs. This is simply not the case. Likewise, most patients with diabetic foot ulcers (DFUs) and poorly healing lower extremity wounds should undergo a thorough noninvasive vascular evaluation. Unfortunately, this often does not occur. A physical exam and palpable pedal pulses are usually adequate to ensure pedal blood flow.
However, a patient can still lose a foot with a palpable pulse and a palpable pulse does not always ensure adequate blood flow. Patients can have chronic total occlusions (CTOs) of the femoral or infrapopliteal vessels, and still have a palpable pulse.
When it comes to most lower extremity wounds, the use of appropriate wound care and adequate revascularization should facilitate significant progress toward healing in three to four weeks. If this does not occur, it should be mandatory to obtain a formal vascular consultation with at least an ankle brachial index (ABI) and a duplex arterial ultrasound. Bear in mind that ABIs can be falsely elevated and appear normal in patients with diabetes due to vascular calcification. A duplex ultrasound is better but it is not perfect. In my experience, the new multislice 16-64 channel CTA has now become the “gold standard” for vascular imaging and is the best of all non-invasive vascular imaging modalities for lower extremity arterial assessment.
Published protocols and data are sparse when it comes to assessing how CLI patients are managed.There are few consensus protocols. In 2004 and 2005, I became strongly suspicious that the majority of CLI patients received an inadequate vascular evaluation and many received referrals for primary amputation without vascular evaluation. At that time, many new “endovascular tools” for complex lower extremity revascularization were under development.
In a retrospective analysis drawn from Medicare database information on a Midwest patient population of 2.5 million CLI patients treated between 2002 and 2003, we analyzed the Medicare data on 417 CLI patients. Our goal was to evaluate how CLI patients were treated and what medical specialties were consulted. We analyzed all data over an 18- month period of time beginning with the index diagnosis.1